Pulmonary Hypertension secondary to HIV

Nicola Petrosillo MD

National Institute for Infectious Diseases “Lazzaro Spallanzani” – Rome, Italy

The emergence of chronic diseases

A clinical case

• 46 y-o female; HIV+ 2000

• Ex IVDU, on methadone

• Within past 4 months:

- shortness of breath

- asthenia, fatigue

- pedal edema

• Physical signs:

- increased pulmonic component of P2

- peripheral edema

- hepatomegaly

• Chest X rays

• ECG

• Echocardio

PASP: 50 mmHg

• Right heart catheterization: mean PASP 50 mmHg, no reply to NO

•HIVRNA 4000 cp/ml CD4+ 690/mmc •HCVAb+ cryoglobulinemia IgGk and cryocrite 4% •HCVRNA 285,000 cp/ml NO TARV

HIV-related pulmonary hypertension NYHA 3

Simonneau G et al. J Am Coll Cardiol 2009; 54: S43-45

Clinical Classification of Pulmonary Hypertension (Dana Point)

HIV associated pulmonary arterial hypertension

-Higher prevalence than in general population -(0.5% versus 0.02%)

Prevalence in HIV population 0.5% (6/1200) Speich, Chest 1991 0.4% (47/11894) Zuber, CID 2004

0.5% (66/13400) Opravil, AIDS 2008

0.5% (35/7648) Sitbon, Am J Respir Crit Care Med 2008

0.4% (19/5000) Cicalini, AIDS 2008

Sitbon O et al. Am J Respir Crit

Care Med 2008; 177: 10813

Opravil, Am J Respir Crit Care Med 1997

N=38

Median 2.6 years

Median 1.3 years

Survival of HIV+ pts with and without PH

Zuber, Clin Infect Dis 2004

p<.005

- Reduction of hazard rate for mortality HR for pts on HAART 0.075; 95% CI,0.02-0.28;p<0.001

Role of HAART-Swiss Cohort Retrospective study- 47 pts with HIV-PAH (1988-2001)

- Reduction of incidence from 0.24% in 1993 to 0.02% in 2001 (HAART)

HAART does not prevent the occurrence of PAH

- 66 pts (1988-2006 )

-19 pts with a new PAH diagnosis after 2001

-2/3 of pts on HAART since at least 3 months at the

diagnosis of HIV-PAH

Opravil, AIDS 2008

Role of HAART-Swiss Cohort

N=66

Sopravvivenza mediana 3.6 anni 84% dei pazienti sopravvissuti ad 1 anno

Role of HAART-Swiss Cohort

Opravil, AIDS 2008

Prognostic factors in HIV-PAH- French Registry

Pts in NYHA class III-IV 1

0,8 p = 0,04

0,6

Epoprostenol + HAART

0,4

0,2

Conventional therapy + HAART

0

0 12 24 36 48 mesi

Overa

ll s

urv

ival

Nunes H, Am J Respir Crit Care Med, 2003

N=16

N=12

Petrosillo N Cicalini S. PVRI Review 2009; 1: 173-9

Pathogenesis

Direct role of HIV • - HIV never isolated in endothelial cells of affected pulmonary

vessels • - Protein Nef in mononucleolar alveolar cells and in endothelial cells

of lung Indirect role of HIV Increased levels of ET-1, IL-1 beta, IL-6, TNF alpha and PDGF alpha 1 adrenergic hypotesis - Chronic stimulation (chronic hypossia, high circulating levels of

norepinephrine, cocaine, appetite suppressant agents) of alpha1adrenergic receptors => excessive proliferation of smooth muscle cells and fibroblasts, pulmonary vascular hypertrophy and excessive vasoconstriction of pulmonary vascular medium-sized arteries

Pathogenesis

Coinfection with hepatitis viruses -Enhanced synthesis and reduced metabolism of ET-1 (in

cirrhosis) - PAPS higher in HIV+ pts with PH and cirrhosis vs

HIV+ pts with PH without cirrhosis Genetic factors HLA DR52 e DR6 ? HHV8 -HHV-8 antigens and genoma in pts with HP (no HIV) -HHV8 represents a common infection in HIV + pts

HHV8 and related clinical manifestations

Emerg Infect Dis 2005;11:1480-2

•is an accessory protein expressed early

during viral infection, together with Tat.

•The Nef protein is a molecular adaptor and is

a key player in HIV pathogenesis.

•For example, Nef complexes with several host

cell proteins (including members of the p21-

activated kinase family), and recruits host

adaptor proteins to commander trafficking of

intracellular vesicles participating in secretory

and endocytic pathways.

HIV Nef (negative factor)

Fackler OT et al. Mol Cell Biol 2000; 20:2619-2627.

Roeth JF et al. Microbiol Mol Biol Rev 2006; 70:548-563.

•Nef downregulates essential molecules such

CD4 receptor by targeting it to the endocytic

degradation pathway in clathrin-coated vesicles

and MHC-1 by sequestering it in the trans-Golgi

and hence, preventing the recycling of this

receptor from the Golgi to the membrane.

HIV Nef (negative factor)

Miller MD et al. J Exp Med 1994; 179:101-113

•Also, Nef is a migratory stimulus for monocytes

and induce the release of inflammatory

molecules. Lehmann MH et al. Exp Cell Res 2006; 312:3659-3668.

Olivetta E et al. J Immunol 2003; 170:1716-1727.

Capoccia BJ et al. J Leukoc Biol 2008; 84:760-768

•The potential of Nef as a vascular insult is underscored by its

capacity to enter lymphocytes via the human chemokine

receptor CXCR4 and exert apoptotic effects (James CO et al. J

Virology 2004; 78:3099-3109).

•Endothelial cells express this receptor and therefore, it is

conceivable that Nef may be present in endothelial cells in the

absence of infection.

•Nef localizes to vascular and perivascular cells (Marecki J et al.

Chest 2005; 128(6 Suppl):621S-622S; Marecki JC et al. Am J Respir Crit Care Med

2006; 174:437-445) and induces apoptosis in brain endothelial cells

when expressed intracellularly or exogenously.

•Nef also impairs vasomotor functions in pulmonary artery

cells, decreases the expression of endothelial nitric oxide

synthase and increases oxidative stress (Duffy P et al. J Surg Res

2009. 53).

Potential clinical role of Nef

Nef is mutated in the lung of a patient

with HRPAH. •Nef sequences in the blood of patients with pulmonary

hypertension show signature patterns that are specific

to this disease phenotype, compared to their

normotensive counterparts (Almodovar S et al. Am J Respir Crit Care

Med 2009; 77:A440.55).

•Peripheral blood samples are the main biological

specimens analyzed in clinical research because lung

tissues from these patients are extremely difficult to

obtain.

•Nevertheless HIV-1 nef sequences from archived lung

tissue from an HRPAH patient from the Italian Latium

Registry of HRPAH (Petrosillo N et al. AIDS 2006; 20:2128-2129) were

amplified and cloned.

Almodovar S et al. Chest 2010; 137(6 Suppl):6S-12S.

Nef is mutated in the lung of a

patient with HRPAH.

The patient was diagnosed with HIV infection in 2000 and with HRPAH in 2006, the same year the patient died.

The lungs were collected during autopsy and subsequently analyzed.

Sequence analyses of the HIV nef showed the presence of 4/5 Nef mutations reported in SHIVnef-infected macaques (Mandell CP et al. Virology 1999; 265:235-251) with plexiform lesions.

Furthermore, this Nef sequence had six Nef functional domains mutated, all of them found only in the lung tissues collected in 2006, and interestingly, none of the mutations was found in PBMC collected at the time of HIV diagnosis.

Almodovar S et al. Chest 2010; 137(6 Suppl):6S-12S.

Figure 2. Phylogenetic reconstruction of HIV-1 nef sequences from a patient diagnosed with HRPAH. Archived PBMC and

lung tissue was obtained from a patient diagnosed with HRPAH by echocardiography, and enrolled in the Latium Registry of HRPAH

in Rome. HIV nef was PCR-amplified, cloned and sequenced; sequences were aligned using BioEdit and the phylogenetic tree was

created using MEGA4. The analysis was statistically supported by 1000 boostrapre-samplings and only values >70% are shown.

Tissue-specific clustering of the nef quasispecies suggest differential evolution at the level of blood (closed circles) and lung (open

circles).

99

99

9992

99

0.03

Peripheral blood

Lung

Chest 2010; 137(6 Suppl):6S-12S.

There are clear

phylogenetic differences

between the

quasispecies of the lung

vs the periphery

Nef is mutated in the lung of a

patient with HRPAH. •These findings suggest either that the viral quasispecies in the lung arose later in the course of infection, or that these variants are replicating more efficiently in the lung than in the periphery.

•These aspects warrant further research efforts in order to validate (and possibly implement) the use of Nef sequences as potential screening tools to identify subjects at risk of HRPAH, especially in the low-resource settings

Almodovar S et al. Chest 2010; 137(6 Suppl):6S-12S.

Inibisce aggregazione PLT

Vasocostrizione

e proliferazione

+ clearance ET

+ produzione NO

TREATMENT OF HIV-PAH Epoprostenol IV

Nunes, Am J Respir Crit Care Med, 2003

Bosentan in HIV-PAH

Sitbon, Am J Respir Crit Care Med 2004

N=16 p<0.001

6MWT NYHA

Bosentan in HIV-PAH

Sitbon, Am J Respir Crit Care Med 2004

Sildenafil and HIV-PAH

• No controlled studies on its efficacy.

• Data on efficacy derive from case series

Schumacher, AIDS 2001

Alp, AIDS 2003

• P.A. 40 mm, right P.A. 22,

left P.A. 14 mm

• Right Ventricle

• Major axis 90 mm

• Minor axis 43 mm

• ED volume 88 ml

• ES volume 62 ml

• EF: 30 % (n.v. 40-60%)

Feb 5, 2007

PAP 41

TPR 15

CI 1,7

WT 470

Feb 13, 2008

PAP 37

TPR 5,6

CI 2,5

WT 576

• P.A. 35 mm, right P.A. 20, left P.A. 15 mm

• Right Ventricle

• Major axis 78 mm

• Minor axis 43 mm

• ED volume 87 ml

• ES volume 46 ml

• EF: 46 % (n.v. 40-60%)

Cardiac NMR at the beginning of sildenafil therapy and 1 year later

• Protease inhibitors (PI) interfere with cyt P 450

Indinavir, saquinavir, darunavir & ritonavir modify FK of sildenafil

Muirhead, Br J Clin Pharmacol 2000

Interactions sildenafil-HAART

RTV => ↑ AUC of sildenafil (11 times; 95%IC 9.0-12.0) ↑ Cmax of sildenafil (3.9 times; 95%IC 3.2-4.9)

Combination of sildenafil & ritonavir should be given with caution

Cicalini S et al. Clin Microbiol Infect 2010

CONCLUSIONS

The current interest in this severe and life

threatening manifestation is based on the

following facts:

• the frequency of pulmonary arterial

hypertension is higher (>600 times) than in the

general population.

• This estimate means that only in North America

and Western Europe, where almost 3.8 million

people are living with HIV, there are about 8 –

10 000 cases of HIV infected patients with likely

severe and life-threatening pulmonary arterial

hypertension.

• PAH occurs independent of the CD4+ cell

count, it is not dependent on presence or

absence of antiretroviral treatment, and may

develop before a patient meets criteria for the

initiation of antiretroviral treatment.

• Recent advances in the pathobiology of PAH

suggest a role of nef gene mutatiopns, viral

coinfections, such as herpes viruses, viral

hepatitis viruses, etc. This could partly explain

the higher frequency of pulmonary arterial

hypertension in HIV infected individuals,

• New and potent drugs against pulmonary

arterial hypertension are available, and

additional drugs are under development. Some

of these drugs can interact with antiretroviral

drugs.

• Finally, there are some controversies in the

role of antiretroviral treatment regarding the

clinical course of PAH.